BOWEL AND VASCULAR
ANASTOMOSES
Prof. Dr. GHULAM SHABIR
VASCULAR ANASTOMOSIS
• Need to be extremely accurate closure and immediately
watertight at the end of operation when vascular clamps
removed ,
• Knots security is important.
• Use monofilament and a traumatic needle .
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a. Pass a right angle clamp gently through the soft
tissue directly on the dorsal aspect of the artery and
direct it away from the larger veins to avoid iatrogenic
injuries. Caution! Avoid accidental penetration of the
dorsal wall of the artery. b. Gently lift the artery with
the vessel-loop to achieve tension in the tissues, thus
facilitating the dissection.
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Different methods for controlling bleeding are demonstrated.
From left to right: doubly applied vessel loop, bulldog
( small metallic vascular clamp), balloon catheter,
loop of ligature, vascular clamp).
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Simple suture
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Kunlin suture
● If an endarterectomy has been performed,
there is a risk of intimal flap dissection at
the downstream edge. To eleminate this
risk, sutures are inserted to secure the
intima. The needle passes from outside to
inside through an endarterectomized part
of the wall and back from inside to outside
through the atheroma to be finally tied on
the outside.
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Patch angioplasty
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End to end anastomosis: stay sutures
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End to end anastomosis: interrupted suture
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End to end anastomosis: continuous suture
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When two vessels with different
diameters are being sutured
end to end, the smaller has to
be slit open and the edges
trimmed to fit the larger one,
which must be cut somewhat
obliquely to avoid kinking.
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End to end anastomosis: single-stitch method
● Used when there is
a difficulty in rotating the
vessels, for example at
a large bifurcation.
● Commensing on the side
nearest the operater, the
sutures are inserted from
within the lumen to
complete the deep or
posterior aspect and then
continued across the anterior
aspect to the starting point.
● Alternatively, a double ended
suture may be commensed
at the midpoint posteriorly and
each side completed in turn.
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End to end anastomosis: inlay technique
● Used for AAA repair.
● Double ended horizontal mattress
suture in the middle of the graft.
● Needles should pass from graft to
aorta
● Take large bites incorporating all
layers.
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Inlay parachute technique
● The double ended
suture is left untied
in order to allow
a number of stitches
to be placed on each
side before the graft
is pulled down onto
the artery.
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Buttressing sutures
● Sutures may be buttressed
with Dacron pieces when
the wall of the artery is
friable and may cut out
causing hemorrhage.
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End to side anastomosis: four quadrant
technique
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End to side anastomosis: parachute technique
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THANKS